INTRODUCTION:

Dying is a part of the normal lifecycle. Death occurs when the heart ceases to function. In general, death is caused by an illness or trauma that overwhelms the compensatory mechanisms of the body. As death approaches, metabolism is reduced, and the body gradually slows down until all functions end. End of life generally refers to the final phase of a patient’s illness when death is imminent. The Institute of Medicine defines end of life as the period during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age, even if death is not clearly imminent¹. A good death is defined as a “one that is free from avoidable death and suffering for patients, families and caregivers in general accordance with the patient’s and family's wishes”². In contrast, a bad death is one in which there is needless suffering, disregard for the patient's or family's wishes or values and a sense among participants or observers that the norms of decency have been offended (Field and Cassel, 1997). A life-threatening illness is an extreme crisis in life on many levels: physical, psychological, familial, social and spiritual (Doka & Morgan, 1993). Most patients and families struggle with a terminal diagnosis and the realization that there is no cure. The challenges faced by them are substantial and potentially overwhelming. These challenges include physical pain, loss of dignity, and a variety of intense emotions. Patients may feel overwhelmed, fearful, powerless, hopeless, and fatigued, and patients may also develop psychiatric symptoms in response, such as anxiety, depression and delirium. The patient's needs and wishes must be respected. Patients need time to think and express their feelings³.

According to WHO Statistics, about Of 56.9 million global deaths in 2016, 40.5 million, or 71%, were due to non-communicable diseases (NCDs). The leading causes of NCD deaths in 2016 were cardiovascular diseases (17.9 million deaths, or 44% of all NCD deaths), cancers (9.0 million, or 22% of all NCD deaths), and respiratory diseases, including asthma and chronic obstructive pulmonary disease (3.8 million of 9% of all NCD deaths). Diabetes caused another 1.6 million deaths⁴.

End-of-life care is the term used for issues and services related to death and dying. Care is given to people near the end of life who have stopped treatment to cure or control their disease. EOL care focuses on the physical care and psychosocial needs of the patient and family The goals for EOL care is to relieve from the suffering, and to provide supportive care during the dying process, to improve the quality of the patient's remaining life, help ensure a dignified death, and provide emotional support to the family.⁵ Caring for patients across the lifespan, nurses are effective advocates for health and wellness at every stage of life. Nurses are the ideal position to identify and address them. Therefore, end-of-life care should be regarded as an integral and essential element of nursing. Since they can be provided in a simple and inexpensive they shall be available in every country. We shall continue to be given high priority, especially in developing countries⁶.

The holistic approach to caring for the terminally ill at the end of life is integral to the health care delivery system. Nurses care for patients in all stages of disease, from death to survivorship. A nurse's care load in a shift can consist of patients in varying phases of illness, presenting a challenge to nurses who must constantly adjust to the different needs of each patient and their families. The attitude of nurses towards death and dying may influence the care nurses can provide to the client. Knowing oneself and recognizing one's feelings about death is a strong foundation for healthy and compassionate caring³. A study conducted by Dunn, Otten and Stephens in 2005⁷showed that an elective course in hospice nursing was effective in decreasing subjects negative attitude towards death, dying and avoidance behaviour.

Compassionate caring brings great rewards, including the joy of relieving suffering and Improved quality of life. Nurses need to have extensive knowledge about end-of-life care to recognize their unique response to illness and support their values and goals; there is a need to prepare them to care for the dying, which has emerged as a priority. The researcher, in her own clinical experience, has observed that the majority of nurses were lacking in knowledge regarding end-of-life care and attitude towards dying patients. Thus, this study may help the nurses to take care of the dying patient.

OBJECTIVES:

1. To assess the existing knowledge regarding End of life care among staff nurses working in selected hospitals, Bengaluru.

2. To determine the attitude regarding End of life care among staff nurses working in selected hospitals, Bengaluru.

3. To evaluate the effectiveness of structured teaching program on knowledge and attitude regarding End of life care among staff nurses working in selected hospitals, Bengaluru.

4. To find the association between pre test knowledge and attitude scores of nurses regarding End of life care with selected socio-demographic variables.

5. To correlate the knowledge with attitude scores of staff nurses regarding End of life care in selected hospitals, Bengaluru.

METHODOLOGY AND DATA COLLECTION PROCEDURE:

RESEARCH APPROACH:

A pre-experimental research approach was used for the study.

RESEARCH DESIGN:

The research design selected for the study is one pre-experimental, one group pre-test post-test design.

VARIABLES OF THE STUDY:

Independent variable: Structured teaching programme.

Dependent variable: Knowledge and attitude of staff nurses regarding end-of-life care.

TARGET POPULATION:

In the present study, the Population comprises of staff nurses working in PMSSY Hospital, Victoria campus.

SETTING OF THE STUDY:

The setting of the study is PMSSY Hospital, Victoria

Campus Bengaluru.

SAMPLE AND SAMPLING:

The Sample for the present study consists of 50 staff nurses working in PMSSY Hospital, Victoria campus.

SAMPLING TECHNIQUE:

A non-probability convenience sampling technique was used in the present study.

INCLUSION CRITERIA:

1. Nurses who are willing to participate in the study.

2. Nurses who are available at the time of data collection.

INSTRUMENT USED FOR STUDY:

To meet the study objectives, the investigator developed the tool. The tool used for the study comprised a structured knowledge questionnaire and an Attitude scale. A self-administered questionnaire was used for data collection and contained three different parts. The first Part was demographic characteristics such as age, gender, marital status, religion, professional qualification, area of work, total work experience and any witness of death in the family. Part two of the data collection tool was a structured knowledge questionnaire that was rated on multiple choice questions consisting of 30 questions, which can be grouped into five categories and aggregated to yield a total score. Total scores can range from 0(the lowest level of knowledge) to 30(the highest level of knowledge). It is categorized into five subscales, including (1) general information on end-of-life (4 items), (2) Physical and physiological changes (7 items), (3) Psychological changes (3 items), (4) Ethical and legal (4 items) (5) Management (12 items). A score of one was given for every correct response, and zero was given for each incorrect response. The resulting scores are interpreted as Adequate knowledge score (75-100%), Moderate knowledge score (50-74%), and Inadequate knowledge score (below 50%). The third Part of the data collection tool was adopted from the Frommelt Attitude Towards Care of Dying (FATCOD) scale used to assess nurses' attitudes towards end-of-life care, which consists of 20 items that scored on a Likert scale ranging from strongly agree = 5 point, agree = 4 point, uncertain = 3 point, disagree = 2 point and strongly disagree=1 point was given. The possible overall scores range from 20 to 100, with higher scores > 75% reflecting a favourable attitude, 51-75% reflecting a Moderate favourable attitude and ≤50% reflecting an unfavourable attitude towards end-of-life care. The scale contains ten negative and ten positive statements, with reversed scores assigned to negative statements.

DATA COLLECTION PROCEDURE:

After obtaining ethical clearance from the ethical review committee of the government college of nursing, Formal administrative permission was obtained from the special officer of PMSSY, Victoria campus, Hospital, Bengaluru, to conduct the study. The data was collected from 04/02/2020 to 04/03/2020. Informed consent was taken from the individual staff nurses after giving oral explanation about the purpose of the study, the procedure of the study, the time it would take to complete the questionnaire ( 20-30 minutes ), the confidentiality of data, voluntary and anonymous participation and that they could withdraw from the study at any time. All the nurses cooperated well during the data collection process.

DATA ANALYSIS:

Data obtained from the sample were coded and entered in MS Excel. And analysed with the use of both descriptive and inferential statistics.

HYPOTHESIS:

H₁: There will be a significant increase in mean post test knowledge scores of staff nurses regarding End of life care in selected hospitals, Bengaluru.

H₂: There will be a favorable attitude among staff nurses regarding End of life care.

H₃: There will be a significant association between pre test knowledge and attitude scores of staff nurses regarding end of life care with selected demographic variables.

H₄: There will be a significant correlation between knowledge and attitude scores among staff nurses regarding end of life care.

RESULT:

SECTION I : Description of demographic variables.

Table 1 frequency and Percentage Distribution of respondents according to selected demographic variables. N=50

Characteristics	Variables	Frequency	%
Age	21 to 30 Years	09	18.0
	31 to 40 Years	35	70.0
	41 to 50 Years	06	12.0
	51 to 60 Years	-	-
Gender	Male	03	6.0
Gender	Female	47	94.0
Religion	Hindu	38	76.0
	Christian	12	24.0
	Muslim	0	0
Marital Status	Single	07	14.0
Marital Status	Married	43	86.0
Professional Qualification	GNM	30	60.0
	BSC	17	34.0
	Post Graduation	03	6.0
Area of Work	General Ward	22	44.0
	ICU	14	28.0
	Emergency	14	28.0
	Oncology Unit	-	-
Experience (Years)	3 and below	04	8.0
	4 to 6 Years	04	8.0
	7 to 9 Years	06	12.0
	10 and above	36	72.0
Witness to death	Yes	29	58.0
Witness to death	No	21	42.0

The table 1 reveals that the majority, 70% of the respondents, were between the age group of 31 - 40 years, and the majority 94%, were female and 6% were male. 86% of them were married, 76% of the respondents belonged to the Hindu religion, 60% of the respondents had General nursing and midwifery nursing, and 44% of the respondents were working in general ward. Based on clinical experience, it shows that the majority, 72% of respondents, had more than ten years of work experience. 58% had exposure to death in the family.

SECTION II: Analysis of overall knowledge and attitude level of respondents regarding end of life care

Part 1: Description of respondents on level of knowledge regarding end of life care

Figure 1: Distribution of respondents on Level of Knowledge on end of life care

Table 2: Range, Mean, Mean percentage, and standard deviation of respondents on level of knowledge regarding end of life care. N=50

TEST	Max. Score	Range of Score	Respondents knowledge			Paired ‘t’ Test
TEST	Max. Score	Range of Score	Mean	SD	Mean (%)	Paired ‘t’ Test
Pre test Knowledge	30	08-25	15.12	3.66	50.40	-15.131
Post test knowledge	30	16-28	22.56	3.47	75.20	-15.131
Enhancement			7.44	3.48	72.22

*Significant at 0.05% level, t (0.05, 49df) = 2.26

Table 2 reveals that the pre-test mean knowledge score was 15.12 with a standard deviation of ± 3.66. The post-test mean knowledge score was 22.56, with a mean deviation of ± 3.47. The paired ‘t’ test (49) = -15.131, which was found to be highly significant at 0.5 level of significance. Score indicating the positive impact of the intervention programme.

Part 2: Description of respondents on level of attitude regarding end of life care

Figure: 2 Distribution of respondents on level of attitude regarding end of life care

Table no 3: Distribution of respondents on level of attitude regarding end of life care. N=50

Test	Level of attitude		Paired ‘t’
Test	Mean	SD
Pre	68.80	6.16	-4.091*
Post	74.22	9.95
Enhancement	5.42	9.37

*Significant at 0.05 Level, t (0.05, 49Df) =2.26

Table 3 shows that respondents' distribution on level of attitude, in the pre-test mean attitude score is 68.80 with a standard deviation of ±6.16, and the post-test mean attitude score is 74.22 with a standard deviation of ± 9.95.. The paired t-test is -4.091, which is more than the table value of 2.26 at a 0.05 level of significance. So, there is a significant impact on the intervention programme.

SECTION III: The Association between Level of knowledge and level of attitude with demographic variables.

The Association between pre-test Level of knowledge with selected demographic variables:

There is a significant association between pre-test level of knowledge with selected demographic variables like religion chi-square (χ²) value is found to be more 3.947 than table value 0.047, In the professional qualification chi-square (χ²) value is found to be more 9.216 than table value 0.010, witness of death in the family chi-square (χ²) value is found to be more 4.023 than table value 0.045.

The Association between the pre-test level of attitude of respondents on end-of-life care with selected demographic variables:

There is a significant association with the level of attitude in the selected demographic variables like professional qualification; the chi-square (χ2 )Value is found to be more 14.118 than the table value (p value= 0.001). There was no significant relation between knowledge of respondent's age, gender, Marital status, religion, area/department of work, years of experience and witness of the death of family members.

SECTION IV: Relationship between knowledge and attitude regarding EOL

Table No 4: Distribution of respondents on Relationship between knowledge and attitude regarding end of life care N=50

Variables

Mean

Pearson correlation

P value

Pre-test knowledge

15.12

3. 66

0.197

0.169

( ≥0.05)*

Pre-test Attitude

68.80

6.16

^{*Non significant}

Table 4 shows that the pre-test knowledge and attitude correlation coefficient was S 0.197. The significance is P = 0.169. There is a positive correlation, but it is not statistically significant because the p-value (0.19) is greater than the 0.05 level of significance. No significant correlation was found between knowledge and attitude.

DISCUSSION:

MAJOR FINDINGS OF THE STUDY:

1. Findings related selected demographic variable:

In the present study, the majority, 70% of the respondents, were between the age group of 31 - 40 years, and the majority 94%, were female and 6% were male. 86% of them were married, 76% of the respondents belonged to the Hindu religion, 60% of the respondents had General nursing and midwifery nursing, and 44% of the respondents were working in general ward. Based on clinical experience, it shows that the majority, 72% of respondents, had more than ten years of work experience. 58% had exposure to death in the family.

2. Findings related to knowledge and attitude of the respondents regarding end of life care:

The overall knowledge level was 75.20%. 50% (25) of the respondents had moderate knowledge 50% (25) were had adequate knowledge. The significance of the difference between the Mean pre-test knowledge scores score is 15.12, and the Mean post-test score is 22.56 with a standard deviation difference ±3.48, which was statistically tested using paired 't' test 15.13 and found to be highly significant at 0.05 level of significance. The attitude level shows that 56% (28) had a moderately favourable attitude, and 44% (22) of respondents had a favourable attitude. None of them had an unfavourable attitude towards end-of-life care. Similarly, there was a significant difference between the mean pre-test attitude score of 68.80 with a standard deviation of ± 6.16, the post-test score is 74.22, with a standard deviation of ± 9.95. Hence, hypothesis H1 and H2 stated in this study is accepted, which showed an increase in respondents' mean post-test knowledge and attitude scores regarding End-of-life care. The findings are supported by Iranmanesh⁸, who found that attitudes towards terminally ill patients will range from neutral to positive. He revealed that nurses' attitude towards dying patient was favourable. Nurses' views on death and personal experiences affected their attitudes towards dying patients. Lack of education and professional limitations may contribute to the negative attitude towards some aspects of care.

3. Findings related to association of knowledge and attitude of the respondents with selected demographic variable:

There was a significant association of knowledge with selected demographic variables such as religion (ꭓ2 = 3.947), professional qualification (ꭓ2 = 9.216) and witness of death of family (ꭓ2 =4.023). This study was supported by Paul Michael Keenan and Ciara Mac Dermott⁹. Spirituality and religion play a vital role in the daily lives of many nurses, who further embrace this aspect of their care when managing dying, death and bereavement. There was a significant association of attitude with selected demographic variables like qualification ((ꭓ2= 14.118). However, years of experience had no significant association with a higher mean score of 1.215 (p-value = 0.749). Hence the hypothesis H3 is accepted. This is supported by Lange M Thomas 56, who suggested that nurses with more experience tended to have a more positive attitude towards death and care of dying patients.

4 Findings related to the Relationship between knowledge and attitude of the respondents regarding end of life care:

The correlation coefficient of level of knowledge and attitude was S 0.197. The significance is P = 0.169. There is a positive correlation, but it is not statistically significant because the p-value (0.197) is greater than the 0.05 level of significance. Hence the hypothesis H4 is rejected. No significant association was found between knowledge and attitude.

SUMMARY:

The present study aimed to assess the effectiveness of structured teaching programmes on knowledge and attitude among staff nurses regarding end-of-life care. The study population consisted of staff nurses working in Victoria Hospital (PMSSY) in Bengaluru. The number of respondents was 50 staff nurses who fulfilled the inclusion criteria. A convenient sampling technique was used to select the respondents. The tool was administered to the samples. The selected subjects were informed about the purpose of the study, and consent was obtained.

The data gathered were analyzed and interpreted according to objectives. Descriptive statistics mean and standard deviation were used. Inferential statistics, Pearson correlation, and chi-square were included to test the hypothesis at different levels of significance, and the data obtained are presented in graphical form.

CONCLUSION:

Study findings reveal that 25(50%) respondents had adequate knowledge, and 25(50%) had moderate knowledge regarding end-of-life care. In the Attitude level of respondents, the majority, 28(56%), had a moderately favourable attitude, and 22(44%) had a favourable attitude towards end-of-life care. There is a statistical significance in the enhancement of knowledge score (7.44), indicating the positive impact of the intervention program. Therefore, the study concluded that Nurses had adequate knowledge and moderately favorable attitudes regarding End-of-life care, and the administration of a structured teaching program was an effective method to improve the knowledge of staff nurses regarding end-of-life care.

IMPLICATIONS OF THE STUDY:

Nursing Practice:

It is indicated that health professionals should make concentrated efforts when providing end-of-life care. It ensures that nurses treat people compassionately and listen to people. Communicate clearly and sensitively. Identify and meet the needs of each individual. Standardized nursing care plans can be prepared to take care of these patients.

Nursing Administration:

Nursing administrators can organize various in-service education and special training programs for the nurses to update their knowledge regarding the care of terminally ill patients.

Nursing Education:

In the current nursing curriculum, students must receive preparation about death and dying before their first clinical placement. Students must be rotated to various clinical speciality areas.

Nursing Research:

The study's findings will serve as a database to develop teaching modules and take up further studies in similar areas.

LIMITATIONS:

1. The sample size for the study was limited to 50 samples of staff nurses . Hence the result of study cannot be generalized.

2. The study is limited to staff nurses working in Victoria hospital (PMSSY) , Bengaluru.

3. Staff nurses who are available at the time of data collection.

RECOMMENDATIONS:

1. The present study can be conducted with a larger population.

2. A comparative study can be conducted between registered nurses, student nurses and health care assistant

3. A similar study can be conducted for other staff nurses and health care professionals who are working in different hospitals

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGEMENT:

The author would like to thank Mr. Narasinga Rao, Lecturer of Mental Health Nursing Department, Government College of Nursing Fort. Bengaluru for his kind support in conducting this project as a part of her requirement in post graduate in nursing M. Sc.(N).

REFERENCE:

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2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874514/

3. Vakkachan R, Varghese A, Bivin JB, Nagarajaiah Study on. knowledge and attitude towards end of life care among student nurses and staff nurses. Indian Journal of Psychiatric Nursing. 2013 Jan; 5: 18-21. Doi: 10.4103/2231-1505.261767. Available online https://journals.lww.com/iopn/fulltext/2013/05010/knowledge_and_attitude_towards_end_of_life_care.6.aspx.

4. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/total-ncd-mortality .

5. Black JM, Howks JH. Medical Surgical Nursing Clinical management for positive outcomes. 8^th ed., Vol.1, Pg.488

6. Robin B R, Hillary H L, Deborah A B et al. The role of palliative care at the end of life. Ochsner Journal. 2011; 11(4): 348-352. PMC3241069. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241069.

7. Karen S Dunn, Cecilia Otten, Elizabeth Stephens. Study on Nursing Experience and the Care of Dying Patients Oncology Nursing Forum. 2005 Jan 19; 32(1): 97-104. Doi: 10.1188/05.ONF.97-104.Available online: https://pubmed.ncbi.nlm.nih.gov/15660148/

8. Sedigheh Iranmanesh, Helen Dargahi, Abbas Abbaszadeh. Study on Attitude of Iranian nurses towards caring for dying patients. 2008 Dec; 6(4): 363-9. Doi: 10.1017/S1478951508000588. Available online https://pubmed.ncbi.nlm.nih.gov/19006591.

9. Paul Michael Keenan, Ciara Mac Dermott. Prayer and religion Irish nurses caring for an intellectually disabled child. 2016; Jun 7(12): 148. Doi: 10.3390/re17120148. Available online: https://www.mdpi.com/2077-1444/7/12/148.

Received on 20.10.2023 Modified on 12.02.2024

Asian J. Nursing Education and Research. 2024; 14(2):123-128.

DOI: 10.52711/2349-2996.2024.00024